To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Choosing Wisely Canada (CWC) is a national initiative designed to encourage patient-clinician discussions about the appropriate, evidence-based use of medical tests, procedures and treatments. The Canadian Association of Emergency Physicians’ (CAEP) Choosing Wisely Canada (CWC) working group developed and released ten recommendations relevant to Emergency Medicine in June 2015 (items 1–5) and October 2016 (items 6–10). In November 2016, the CAEP CWC working group developed a process for updating the recommendations. This process involves: 1) Using GRADE to evaluate the quality of evidence, 2) reviewing relevant recommendations on an ad hoc basis as new evidence emerges, and 3) reviewing all recommendations every five years. While the full review of the CWC recommendations will be performed in 2020, a number of high-impact studies were published after our initial launch that prompted an ad hoc review of the relevant three of our ten recommendations prior to the full review in 2020. This paper describes the results of the CAEP CWC working group's ad hoc review of three of our ten recommendations in light of recent publications.
Residual herbicides applied to summer cash crops have the potential to injure subsequent winter annual cover crops, yet little information is available to guide growers’ choices. Field studies were conducted in 2016 and 2017 in Blacksburg and Suffolk, Virginia, to determine carryover of 30 herbicides commonly used in corn, soybean, or cotton on wheat, barley, cereal rye, oats, annual ryegrass, forage radish, Austrian winter pea, crimson clover, hairy vetch, and rapeseed cover crops. Herbicides were applied to bare ground either 14 wk before cover crop planting for a PRE timing or 10 wk for a POST timing. Visible injury was recorded 3 and 6 wk after planting (WAP), and cover crop biomass was collected 6 WAP. There were no differences observed in cover crop biomass among herbicide treatments, despite visible injury that suggested some residual herbicides have the potential to effect cover crop establishment. Visible injury on grass cover crop species did not exceed 20% from any herbicide. Fomesafen resulted in the greatest injury recorded on forage radish, with greater than 50% injury in 1 site-year. Trifloxysulfuron and atrazine resulted in greater than 20% visible injury on forage radish. Trifloxysulfuron resulted in the greatest injury (30%) observed on crimson clover in 1 site-year. Prosulfuron and isoxaflutole significantly injured rapeseed (17% to 21%). Results indicate that commonly used residual herbicides applied in the previous cash crop growing season result in little injury on grass cover crop species, and only a few residual herbicides could potentially affect the establishment of a forage radish, crimson clover, or rapeseed cover crop.
Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration.
An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback.
Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program.
A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.
We conducted an environmental scan of quality improvement and patient safety (QIPS) infrastructure and activities in academic emergency medicine (EM) programs and departments across Canada.
We developed 2 electronic surveys through expert panel consensus to assess important themes identified by the CAEP QIPS Committee. “Survey 1” was sent by email to all 17 Canadian medical school affiliated EM department Chairs and Academic Hospitals department Chiefs; “Survey 2” to 12 identified QIPS leads in these hospitals. This was followed by 2 monthly email reminders to participate in the survey.
22/70 (31.4%) Department Chairs/Chiefs completed Survey 1. Most (81.8%) reported formal positions dedicated to QIPS activities within their groups, with a mixed funding model. Less than half of these positions have dedicated logistical support. 11/12 (91.7%) local QIPS leads completed Survey 2. Two-thirds (63.6%) reported explicit QIPS topics within residency curricula, but only 9.1% described QIPS training for staff physicians. Many described successful academic scholarship output, with the total number of peer-reviewed QIPS-related publications per centre ranging from 1–10 over the past 5 years. Few respondents reported access to academic supports: methodologists (27.3%), administrative personnel (27.3%), and statisticians (9.1%).
This environmental scan provides a snapshot of QIPS activities in EM across academic centres in Canada. We found significant local educational and academic efforts, although there is a discrepancy between the level of formal support/infrastructure and such activities. There remains opportunity to further advance QIPS efforts on a national level, as well as advocating and supporting local QIPS activities.
The analysis of copper alloys is a classical case for X-ray fluorescence as an analytical technique. For many years, large wavelength dispersive X-ray spectroraeters have been used in process control associated with the manufacture of brasses, bronzes and coinage alloys. For the last two to three years, a new, benchtop WDX multichannel spectrometer, the Chem-X, has been successfully introduced for the same purpose.
Two types of mentalisation-based treatment (MBT) have been developed and empirically evaluated for borderline personality disorder (BPD): day hospital MBT (MBT-DH) and intensive out-patient MBT (MBT-IOP). No trial has yet compared their efficacy.
To compare the efficacy of MBT-DH and MBT-IOP 18 months after start of treatment. MBT-DH was hypothesised to be superior to MBT-IOP because of its higher treatment intensity.
In a multicentre randomised controlled trial (Nederlands Trial Register: NTR2292) conducted at three sites in the Netherlands, patients with BPD were randomly assigned to MBT-DH (n = 70) or MBT-IOP (n = 44). The primary outcome was symptom severity (Brief Symptom Inventory). Secondary outcome measures included borderline symptomatology, personality functioning, interpersonal functioning, quality of life and self-harm. Patients were assessed every 6 months from baseline to 18 months after start of treatment. Data were analysed using multilevel modelling based on intention-to-treat principles.
Significant improvements were found on all outcome measures, with moderate to very large effect sizes for both groups. MBT-DH was not superior to MBT-IOP on the primary outcome measure, but MBT-DH showed a clear tendency towards superiority on secondary outcomes.
Although MBT-DH was not superior to MBT-IOP on the primary outcome measure despite its greater treatment intensity, MBT-DH showed a tendency to be more effective on secondary outcomes, particularly in terms of relational functioning. Patients receiving MBT-DH and MBT-IOP, thus, seem to follow different trajectories of change, which may have important implications for clinical decision-making. Longer-term follow-up and cost-effectiveness considerations may ultimately determine the optimal intensity of specialised treatments such as MBT for patients with BPD.
Declaration of interest
P.L. and D.L.B. have been involved in the training and dissemination of MBT.
Chemical weed control remains a widely used component of integrated weed management strategies because of its cost-effectiveness and rapid removal of crop pests. Additionally, dicamba-plus-glyphosate mixtures are a commonly recommended herbicide combination to combat herbicide resistance, specifically in recently commercially released dicamba-tolerant soybean and cotton. However, increased spray drift concerns and antagonistic interactions require that the application process be optimized to maximize biological efficacy while minimizing environmental contamination potential. Field research was conducted in 2016, 2017, and 2018 across three locations (Mississippi, Nebraska, and North Dakota) for a total of six site-years. The objectives were to characterize the efficacy of a range of droplet sizes [150 µm (Fine) to 900 µm (Ultra Coarse)] using a dicamba-plus-glyphosate mixture and to create novel weed management recommendations utilizing pulse-width modulation (PWM) sprayer technology. Results across pooled site-years indicated that a droplet size of 395 µm (Coarse) maximized weed mortality from a dicamba-plus-glyphosate mixture at 94 L ha–1. However, droplet size could be increased to 620 µm (Extremely Coarse) to maintain 90% of the maximum weed mortality while further mitigating particle drift potential. Although generalized droplet size recommendations could be created across site-years, optimum droplet sizes within each site-year varied considerably and may be dependent on weed species, geographic location, weather conditions, and herbicide resistance(s) present in the field. The precise, site-specific application of a dicamba-plus-glyphosate mixture using the results of this research will allow applicators to more effectively utilize PWM sprayers, reduce particle drift potential, maintain biological efficacy, and reduce the selection pressure for the evolution of herbicide-resistant weeds.
There is an unprecedented demand for bushmeat in large cities in sub-Saharan Africa, and this is a major threat to many species. We conducted 2,040 interviews in six cities in four West African countries, in forest and savannah settings. We analysed age- and sex-related differences in the frequency of bushmeat consumption. Overall, we found similar patterns in all cities: 62.2% of men and 72.1% of women said they would never eat bushmeat, whereas 12.8% of men and 8.8% of women said they liked bushmeat and ate it regularly. Younger generations of both sexes tended not to eat bushmeat, regardless of their city of origin. This study of the effects of age, gender and geographical location on bushmeat consumption in African cities provides insights regarding which population groups to target in campaigns to change behaviours.
The 13-valent pneumococcal conjugate vaccine (PCV) has been part of routine immunisation in a 2 + 1 schedule (two primary infant doses and one booster during the second year of life) in the UK since 2010. Recently, the UK's Joint Committee on Vaccination and Immunisation recommended changing to a 1 + 1 schedule while conceding that this will increase disease burden; however, uncertainty remains on how much pneumococcal burden – including invasive pneumococcal disease (IPD) and non-invasive disease – will increase. We built a dynamic transmission model to investigate this question. The model predicted that a 1 + 1 schedule would incur 8777–27 807 additional cases of disease and 241–743 more deaths over 5 years. Serotype 19A caused 55–71% of incremental IPD cases. Scenario analyses showed that booster dose adherence, effectiveness against carriage and waning in a 1 + 1 schedule had the most influence on resurgence of disease. Based on the model assumptions, switching to a 1 + 1 schedule will substantially increase disease burden. The results likely are conservative since they are based on relatively low vaccine-type pneumococcal transmission, a paradigm that has been called into question by data demonstrating an increase of IPD due to several vaccine serotypes during the last surveillance year available.
Quality improvement (QI) and patient safety are two areas that have grown into important operational and academic fields in recent years in health care, including in emergency medicine (EM). This is the third and final article in a series designed as a QI primer for EM clinicians. In the first two articles we used a fictional case study of a team trying to decrease the time to antibiotic therapy for patients with sepsis who were admitted through their emergency department. We introduced concepts of strategic planning, including stakeholder engagement and root cause analysis tools, and presented the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles as the backbone of the execution of a QI project. This article will focus on the measurement and evaluation of QI projects, including run charts, as well as methods that can be used to ensure the sustainability of change management projects.
Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.
A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.
Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).
Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.
This study presents a complete characterization of kenoplumbomicrolite, (Pb,□)2Ta2O6[□,(OH),O], occurring in an amazonite pegmatite from Ploskaya Mountain, Western Keivy Massif, Kola Peninsula, Murmanskaja Oblast, Northern Region, Russia.
Kenoplumbomicrolite occurs in yellowish brown octahedral, cuboctahedral and massive crystals, up to 20 cm, has a white streak, a greasy lustre and is translucent. The Mohs hardness is ~6. Attempts to measure density (7.310–7.832 g/cm3) were affected by the ubiquitous presence of uraninite inclusions. Reflectance values were measured in air and immersed in oil. Kenoplumbocrolite is optically isotropic. The empirical formula is (Pb1.30□0.30Ca0.29Na0.08U0.03)Σ2.00(Ta0.82Nb0.62Si0.23Sn4+0.15Ti0.07Fe3+0.10Al0.01)Σ2.00O6[□0.52(OH)0.25O0.23]Σ1.00 (from the crystal used for the structural study) and (Pb1.33□0.66Mn0.01)Σ2.00(Ta0.87Nb0.72Sn4+0.18Fe3+0.11W0.08Ti0.04)Σ2.00O6[□0.80(OH)0.10O0.10]Σ1.00 (average including additional fragments). The mineral is cubic, space group Fd
$\overline 3 $
m. The unit-cell parameters refined from powder X-ray diffraction data are a = 10.575(2) Å and V = 1182.6(8) Å3, which are in accord with those obtained previously from a single crystal of a = 10.571(1) Å, V = 1181.3(2) Å3 and Z = 8. The mineral description and its name have been approved by the Commission on New Minerals, Nomenclature and Classification of the International Mineralogical Association (IMA2015-007a).
Nine species of the gall-associated doryctine genus Allorhogas Gahan (Hymenoptera: Braconidae) are described from Brazil (A. clidemiae Martínez and Zaldívar-Riverón new species, A. granivorus Zaldívar-Riverón and Martínez new species, A. mineiro Zaldívar-Riverón and Martínez new species, and A. vulgaris Zaldívar-Riverón and Martínez new species) and Costa Rica (A. brevithorax Zaldívar-Riverón and Martínez new species, A. pallidus Martínez and Zaldívar-Riverón new species, A. psychotria Zaldívar-Riverón and Martínez new species, A. punctatus Martínez and Zaldívar-Riverón new species, and A. tico Martínez and Zaldívar-Riverón new species). We provide host plant records for the described species, including information that reveals that at least three of them feed on seeds. Allorhogas granivorus had previously been confirmed to represent a natural enemy of the invasive weed Miconia calvescens de Candolle (Melastomataceae). Updated keys to the species of Allorhogas from Brazil and Costa Rica are provided.
A large outbreak of Legionnaires’ disease occurred at a California state prison in August 2015. We conducted environmental and epidemiological investigations to identify the most likely source of exposure and characterise morbidity. Sixty-four inmates had probable Legionnaires’ disease; 14 had laboratory-confirmed legionellosis. Thirteen (17%) inmates were hospitalised; there were no deaths. Ill inmates were more likely to be ⩾65 years old (P < 0.01), have the chronic obstructive pulmonary disease (P < 0.01), diabetes mellitus (P = 0.02), hepatitis C infection (P < 0.01), or end-stage liver disease (P < 0.01). The case-patients were in ten housing units throughout the prison grounds. All either resided in or were near the central clinical building (for appointments or yard time) during their incubation periods. Legionella pneumophila serogroup 1 was cultured from three cooling towers on top of the central medical clinic (range, 880–1200 cfu/ml). An inadequate water management program, dense biofilm within the cooling towers, and high ambient temperatures preceding the outbreak created an ideal environment for Legionella sp. proliferation. All state prisons were directed to develop local operating procedures for maintaining their cooling towers and the state health department added a review of the maintenance plans to their environmental inspection protocol.
The course of illness in obsessive–compulsive disorder (OCD) varies significantly between patients. Little is known about factors predicting a chronic course of illness. The aim of this study is to identify factors involved in inducing and in maintaining chronicity in OCD.
The present study is embedded within the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, an ongoing multicenter naturalistic cohort study designed to identify predictors of long-term course and outcome in OCD. For this study, 270 subjects with a current diagnosis of OCD were included. Chronicity status at 2-year follow-up was regressed on a selection of baseline predictors related to OCD, to comorbidity and to stress and support.
Psychotrauma [odds ratio (OR) 1.98, confidence interval (CI) 1.22–3.22, p = 0.006], recent negative life events (OR 1.42, CI 1.01–2.01, p = 0.043), and presence of a partner (OR 0.28, CI 0.09–0.85, p = 0.025) influenced the risk of becoming chronic. Longer illness duration (OR 1.46, CI 1.08–1.96, p = 0.013) and higher illness severity (OR 1.09, CI 1.03–1.16, p = 0.003) increased the risk of remaining chronic.
External influences increase the risk of becoming chronic, whereas the factors involved in maintaining chronicity are illness-related. As the latter are potentially difficult to modify, treatment should be devoted to prevent chronicity from occurring in the first place. Therapeutic strategies aimed at alleviating stress and at boosting social support might aid in achieving this goal.